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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 01/27/2026
Date Signed: 01/29/2026 06:13:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/15/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20251015114407
FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:OWENS, JESSICAFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Bailey Malagon, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility failed to meet a residents needs in a timely manner.
INVESTIGATION FINDINGS:
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On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were 4 staff providing care and 25 residents.

During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20251015114407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775
VISIT DATE: 01/27/2026
NARRATIVE
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Allegation Facility failed to meet a residents needs in a timely manner.

It was alleged that on October 8, 2025, staff were assisting a Resident (R1) with transferring to the restroom. After assisting R1 with sitting down, staff allowed R1 privacy and informed R1 "they would return in a few minutes." It was alleged that no staff returned to assist R1 for approximately 1.5 hours. R1 reported they verbally called for assistance, however, no staff returned. R1 attempted to get up themselves resulting in a fall where they hit their head. R1 reported they were on the floor for approximately 15 more minutes before staff arrived to help. R1 reported they did not use the bathroom's pull cord for assistance as "we were told they didn't work. " (See complaint investigation #59-AS-20251021112112).

R1 indicated they knew the length of time they were left unattended because they were wearing a watch. R1 stated they were left in the bathroom at approximately 7:30 pm and by 9:00 pm nobody had returned. LPA reviewed R1's care notes for March 8, 2025. Care staff noted at 9:50 PM, "Resident attempted to get off the toilet without assistance and landed on butt on the floor. No injury and staff assisted him up. No further concern. MD notified." R1 indicated staff asked if R1 was alright after the fall and then assisted R1 to their bed. Emergency Medical Services (EMS) were not contacted to evaluate R1 for injuries.

On March 9, 2025, care notes indicated R1's family member had informed staff of a red bump on R1's head. R1 stated it was from where they had hit their head the night before.

LPA reviewed R1's LIC 602 (Medical Assessment) dated August 21, 2025, which indicated R1 had no cognitive conditions and was unable to care for their own toileting needs. LPA reviewed R1's care plan dated July 1, 2025, which indicated "Staff to provide hands-on assistance for bladder or bowel incontinence management."

LPA attempted to interview staff members who were present at the time of the incident, but received no return phone calls. Additionally, staff who recorded the care notes documenting the incident are no longer employed at the facility.

Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Bailey Malagon.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20251015114407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2026
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This violation is evidenced by:
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Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of busness on February 2, 2026. Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit an agenda of this training and a signed staff attendance to LPA by end of busness on February 20, 2026.
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Based on interview and record review, the licensee failed to meet the residents needs in that they did not follow the resident's care plan to provide hands on toileting asisitance and they left the resident unattended for approximately 1.5 hours, resulting in R1 sustaining a fall and injury, which poses a potential health, safety, or personal rights risk to resident's in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
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